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Waitlist for Products and Services Interest Form
Contact Information
Name of Parent/ Guardian
*
First Name
Last Name
Email
*
Verify Email
*
Phone
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Preferred Contact Method
*
Email
Phone Call
Text Message
Services of Interest
Are you interested in:
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Enrolling your child at EnCompass Academy
TBRI™ Caregiver Training
Parent Coaching/ Consultation
Spelling to Communicate (S2C™) Consultation
The 6 Types Working Genius® Consultation
Tutoring Services
Educational Consultation
Student/ Child Information
Student/ Child's Name
*
First Name
Last Name
Date of Birth
*
(mm/dd/yyyy)
Current School/ Educational Program Student Attends
*
Current Grade
*
select one
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Graduated
Does your student/ child currently receive any supports/ services?
*
What information would you like us to know about your student/ child?
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Eg- educational or medical diagnosis, sensory needs, why you are looking to enroll, etc.
Background Information
Ages of children in home
What training or support (if any) have you received on parenting/ child care?
*
I understand that submitting this form does not guarantee enrollment in services and that additional information or assessments may be required.
*
I agree